A macrosomic infant is born after a difficult delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to:
Leave the infant in the room with the mother.
Take the infant immediately to the nursery.
Monitor blood glucose levels frequently, and observe closely for signs of hypoglycemia.
Perform a gestational age assessment to determine if the infant is LGA.
The Correct Answer is C
Choice A rationale
Keeping the infant in the mother’s room without further evaluation increases the risk of missed complications like hypoglycemia. Monitoring and interventions are crucial for infants at risk due to macrosomia or difficult delivery.
Choice B rationale
Immediate nursery transfer without specific monitoring or intervention overlooks the infant’s risk for hypoglycemia and its symptoms, such as jitteriness or poor feeding. Further evaluation is more appropriate.
Choice C rationale
Macrosomic infants are at higher risk for hypoglycemia due to increased insulin levels post-birth. Frequent glucose monitoring and vigilance for signs like jitteriness or lethargy are crucial for timely intervention.
Choice D rationale
While gestational age assessment confirms LGA status, it does not address the immediate risk of hypoglycemia. Focus should remain on monitoring and stabilizing glucose levels in at-risk macrosomic infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Postpartum hemorrhage may occur weeks after delivery due to subinvolution of the uterus or retained placental fragments. Educating about late risks ensures patients monitor symptoms and seek timely care.
Choice B rationale
Breastfeeding is encouraged even after postpartum hemorrhage as it helps stimulate uterine contractions, reducing bleeding risk. Recommending avoidance could delay recovery and is scientifically unsupported unless contraindicated.
Choice C rationale
Oxytocin may be prescribed for ongoing uterine atony or to prevent late postpartum hemorrhage. It is essential to educate patients about its purpose and correct administration for safety and effectiveness.
Choice D rationale
Saturating a peri-pad within 1 hour may indicate active bleeding. Reporting this promptly ensures swift intervention to prevent further complications, aligning with standard postpartum care protocols.
Choice E rationale
Postpartum hemorrhage is not limited to 24–48 hours after birth; late-onset hemorrhage, occurring up to weeks later, is a known complication. Misleading patients with this incorrect timeframe can delay critical interventions.
Correct Answer is D
Explanation
Choice A rationale
A soft uterus indicates uterine atony, a complication rather than a normal finding. Daily fundal palpation ensures involution but should result in a firm, not soft, uterus.
Choice B rationale
Passage of clots is common postpartum, but ongoing monitoring for excessive clotting is crucial as it may indicate retained placental fragments or incomplete uterine involution.
Choice C rationale
Decreased lochia does not indicate complications unless it is completely absent, which may suggest uterine or cervical obstruction and warrants further evaluation.
Choice D rationale
Increased lochia or bright red bleeding signifies secondary postpartum hemorrhage, often caused by retained placental tissue or subinvolution, requiring immediate medical attention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.